Inspection Report Summary
The most recent inspection on December 4, 2025, found the facility in compliance with all regulations after correcting one previously identified violation. Earlier inspections showed a pattern of deficiencies related mainly to resident care issues such as timely notification of physicians and families, toileting assistance, medication transcription errors, and staffing levels. Several complaint investigations substantiated violations involving abuse investigations, failure to protect residents, and incomplete or delayed reporting and follow-up on incidents. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows improvement over time, with recent inspections indicating corrected deficiencies and compliance with regulations.
Deficiencies (last 8 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a December 2025 inspection.
Census over time
Inspection Report
Monitoring| Name | Title | Context |
|---|---|---|
| Siobhan O'Neill | Survey Team Leader | Lead surveyor conducting the inspection |
| Maureen Golas-Markure | Supervisor | Supervising nurse consultant/health program supervisor |
| Rosemary Beaudoin | Administrator | Personnel contacted during inspection |
Inspection Report
Monitoring| Name | Title | Context |
|---|---|---|
| Rosemary Beaudoin | Administrator | Notified of correction of violations #1 and #2 |
Inspection Report
| Name | Title | Context |
|---|---|---|
| Linda Legall Tyndele | DNS | Personnel contacted during the inspection |
| Judith Otwoma | Report submitted by |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Rosemary Beaudoin | Administrator | Personnel contacted during the inspection. |
| Linda Legall Tyndale | DNS | Personnel contacted during the inspection. |
Inspection Report
| Name | Title | Context |
|---|---|---|
| Rosemary Beaudoin | Administrator | Named as personnel contacted and notified of violation correction. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Rosemary Beaudoin | Administrator | Personnel contacted during the inspection. |
| Connie Vumback | RN | Report submitted by. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed the notice letter from the Facility Licensing & Investigations Section. |
| RN #4 | Registered Nurse | Nurse responsible for transcribing Resident #2's medication orders and identified in the medication error finding. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Rosemary Beaudoin | Administrator | Personnel contacted during the inspection. |
| Jessica Cusano | ADNS | Personnel contacted during the inspection. |
| Melissa Talamini | Nurse Consultant | Report submitted by and signed nurse consultant. |
Inspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed the notice letter regarding violations and plan of correction instructions |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Deborah Smith | RN, NC | Signature of FLIS Staff and report submitter |
| Rosemary Beaudoin | Administrator | Personnel contacted during inspection |
| Lucia Dike | DNS | Personnel contacted during inspection |
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Rosemary Blando | Administrator | Personnel contacted during inspection |
| Lucas Pike | DNS | Personnel contacted during inspection |
Inspection Report
| Name | Title | Context |
|---|---|---|
| Lucia Duke | Director of Nursing | Personnel contacted during the inspection |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Rosemary Beaudoin | Administrator | Administrator contacted and responsible for monitoring plan of correction |
| Karen Gworek | Supervising Nurse Consultant | Signed the notice letter regarding violations and plan of correction |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Nicholas Tomczyk | Nurse Consultant | Conducted the complaint investigation and authored the licensing inspection report. |
| Rosemary Beaudoin | Administrator | Named in relation to the inspection and findings. |
| Maureen Golas Markure | Supervising Nurse Consultant | Signed the important notice letter regarding the inspection findings. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Norma Schuberth | Supervising Nurse Consultant | Signed the notice letter and referenced in relation to complaint investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Rosemarie Beaudoin | Administrator | Named as personnel contacted and responsible for monitoring the plan of correction. |
| Lucia Dikes | DNS (Director of Nursing Services) | Named as personnel contacted and responsible for monitoring the plan of correction. |
| Judith Birtwistle | Supervising Nurse Consultant | Signed the notice letter regarding the complaint investigation. |
| RN #1 | Nurse Supervisor | Involved in investigation and interviews related to Resident #10's mistreatment allegation. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| RN #1 | Nurse Supervisor | Named in failure to report and investigate allegation of mistreatment |
| DNS | Director of Nursing Services | Named in failure to be aware of police call and failure to ensure investigation completion |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Rosemary Beaudoin | Administrator | Named as personnel contacted during the inspection. |
| Lucia Dike | DNS (Director of Nursing Services) | Named as personnel contacted during the inspection and involved in findings. |
| Karen Gworek | Supervising Nurse Consultant | Author of the notice letter regarding violations and plan of correction. |
| Laura Trombley Norton | RN | Signature on the licensing inspection report and report submitter. |
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Karen Chadderton | Administrator | Personnel contacted during the inspection |
Inspection Report
Original Licensing| Name | Title | Context |
|---|---|---|
| Karen Chadderton | Administrator | Named as facility administrator receiving the report |
| Norma Schuberth | Supervising Nurse Consultant | Signed the notice letter and responsible for Facility Licensing and Investigations Section |
| LPN #1 | Identified in multiple observations and interviews related to medication and grievance findings | |
| LPN #2 | Identified in medication and equipment cleaning observations | |
| RN #1 | Interviewed regarding grievance process and medication room findings | |
| Director of Social Services | Responsible for monitoring grievance plan of correction | |
| Director of Environment | Interviewed regarding smoking supervision and ashtray use | |
| Director of Nursing | Responsible for monitoring oxygen therapy and medication plan of correction | |
| Assistant Director of Nursing | Responsible for monitoring call bell placement plan of correction | |
| Infection Preventionist | Responsible for monitoring infection control and hand hygiene plans of correction | |
| Assistant Director of Dietary | Interviewed regarding food labeling and infection control in kitchen | |
| Food Service Director | Responsible for monitoring food service compliance |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| LPN #1 | Identified expired medications and narcotic box storage issues. | |
| RN #1 | Unaware of missing resident phone and grievance process. | |
| RN #2 | Identified expired Heparin lock flush and disposed of it. | |
| Director of Nursing (DNS) | Director of Nursing | Responsible for medication cart review and narcotic box storage. |
| Assistant Director of Dietary | Reported issues with food labeling and dating. | |
| Director of Dietary | Provided expectations on PPE use and food labeling. | |
| Infection Control Nurse (ICN) | Identified hand hygiene deficiencies during meal delivery. | |
| Social Worker #1 | Interviewed about missing resident phone grievance. | |
| Social Worker #2 | Unaware of missing resident phone grievance. | |
| LPN #2 | Identified cleaning issues with feeding tube equipment. | |
| Administrator | Identified smoking supervision issues. | |
| Director of Environment | Identified smoking supervision and ashtray use issues. |
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Karen Chadderton | Administrator | Personnel contacted during inspection |
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Karen Chadderdon | Administrator | Personnel contacted during inspection |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Jacqueline Ruot | Supervising Nurse Consultant | Signed the notice letter and involved in the investigation |
| Karen Chadderton | Administrator | Facility administrator named in correspondence and plan of correction |
| Director of Nurses | Interviewed regarding incident reporting and clinical record documentation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Karen Chadderton | Administrator | Named as facility administrator in the report. |
| LPN #4 | Licensed Practical Nurse | Involved in failure to notify responsible party and failure to document wound characteristics. |
| Director of Nursing | Director of Nursing | Interviewed regarding notification failures and infection control practices. |
| RN #1 | Registered Nurse | Interviewed about lack of awareness of open wound prior to hospital transfer. |
| RN #2 | Infection Control Preventionist | Interviewed regarding wound assessment and infection control practices. |
| LPN #2 | Licensed Practical Nurse | Interviewed about evaluation of resident's condition and failure to notify supervisor. |
| NA #1 | Nursing Assistant | Observed pushing clean linen cart into residents' rooms against policy. |
| NA #2 | Nursing Assistant | Observed bringing linen cart into residents' rooms and interviewed about infection control. |
| LPN #1 | Licensed Practical Nurse | Interviewed about instructing NA #2 not to bring linen carts into residents' rooms. |
Inspection Report
Abbreviated Survey| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Received order for new treatment on 12/30/20, failed to notify responsible party and nursing supervisor |
| Director of Nursing | Interviewed regarding notification failures and infection control practices | |
| RN #1 | Registered Nurse | Unaware of open wound on Resident #1 prior to hospital transfer |
| RN #2 | Infection Control Preventionist | Informed of open wound after hospital transfer; responsible for monitoring infection control plan |
| NA #1 | Nurse Aide | Observed pushing clean linen cart into residents' rooms contrary to infection control policy |
| NA #2 | Nurse Aide | Observed bringing linen cart into residents' rooms despite awareness of policy |
| LPN #1 | Licensed Practical Nurse | Instructed NA #2 not to bring linen carts into residents' rooms |
Inspection Report
Routine| Name | Title | Context |
|---|---|---|
| Nursing Assistant (NA) #1 | Provided information about dining room observations and seating arrangements | |
| Registered Nurse (RN) #1 | Indicated social distancing was an oversight during the noon meal | |
| Infection Control Nurse (ICN) | Indicated communal dining had been placed on hold and social distancing guidelines | |
| Director of Nursing (DON) | Stated responsibility of nursing staff to ensure social distancing and seating arrangements |
Inspection Report
Abbreviated Survey| Name | Title | Context |
|---|---|---|
| Lisa A. DiLorenzo | Supervising Nurse Consultant | Signed the notice letter |
| Karen Chadderton | Administrator | Addressee of the notice and plan of correction |
| RN #1 | Registered Nurse | Interviewed regarding dining room social distancing |
| RN #2 | Registered Nurse | Observed during mealtime and interviewed regarding dining room social distancing |
| NA #1 | Nursing Assistant | Interviewed regarding dining room usage and seating |
| Director of Nursing | Director of Nursing | Interviewed regarding responsibility for social distancing and monitoring plan of correction |
Inspection Report
Abbreviated SurveyInspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Karen Chadderton | Administrator | Named as recipient of the notice and responsible for facility compliance |
| Lisa A. Dilorenzo | Supervising Nurse Consultant | Author of the plan of correction notice |
Inspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Lisa A. DiLorenzo | Supervising Nurse Consultant | Signed letter and contact for questions regarding violations. |
| Karen Chadderton | Administrator | Recipient of the notice and responsible for monitoring plan of correction. |
| Director of Nursing | Interviewed regarding delay in reporting the event. |
Inspection Report
Abbreviated SurveyInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lisa A. DiLorenzo | Supervising Nurse Consultant | Signed the initial notice letter and involved in the investigation. |
| Karen H. Chadderton | Administrator | Facility administrator who submitted the Plan of Correction. |
| Social Worker #1 | Involved in discharge planning and communication with Money Follows The Person program. | |
| Director of Nursing | Director of Nursing | Interviewed regarding awareness of discharge concerns. |
| Director of Social Work | Director of Social Work | Responsible for case management and follow-up on discharge plan compliance. |
Inspection Report
RoutineInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Assessed Resident #1 after dialysis facility reported injury |
| Director of Nursing | Director of Nursing | Received report from RN #1 and did not report injury as potential abuse; could not locate investigative interviews |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lisa A. DiLorenzo | Supervising Nurse Consultant | Signed letter as Supervising Nurse Consultant for Facility Licensing and Investigations Section |
Inspection Report
Abbreviated Survey| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed not wearing N95 mask on COVID-19 positive unit and interviewed regarding PPE use |
| LPN #1 | Licensed Practical Nurse | Observed wearing surgical mask instead of N95 on COVID-19 positive unit and interviewed regarding PPE use |
| NA #1 | Nursing Assistant | Observed wearing N95 mask improperly and instructed on proper use |
| NA #2 | Nursing Assistant | Observed wearing double surgical masks instead of N95 and interviewed regarding PPE use |
| Director of Nursing | Director of Nursing | Interviewed regarding PPE guidance and facility education plans |
Inspection Report
Routine| Name | Title | Context |
|---|---|---|
| Lisa A. DiLorenzo | Supervising Nurse Consultant | Author of the notice and contact for questions regarding violations |
| Karen H. Chadderton | Administrator | Facility administrator who submitted the plan of correction |
| RN #1 | Registered Nurse | Observed not wearing N95 mask on COVID-19 positive unit and involved in medication administration |
| LPN #1 | Licensed Practical Nurse | Observed not wearing N95 mask on COVID-19 positive unit |
| NA #1 | Nursing Assistant | Observed wearing blue surgical mask under N95 mask incorrectly |
| NA #2 | Nursing Assistant | Observed wearing double blue surgical masks and not wearing N95 mask |
| Director of Nursing | Provided information on mask guidance and responsible for monitoring plan of correction |
Inspection Report
Routine| Name | Title | Context |
|---|---|---|
| Karen Chadderton | Administrator | Personnel contacted during the inspection. |
Inspection Report
Abbreviated SurveyInspection Report
Abbreviated SurveyInspection Report
Abbreviated SurveyInspection Report
RoutineInspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Heidi Caron | Supervising Nurse Consultant | Named as the contact for questions regarding deficiencies and instructions |
| Karen Chadderton | Administrator | Named in relation to the plan of correction and monitoring responsibilities |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lucia Dike | Director of Nursing Services | Contacted personnel during inspection |
| Nicholas Tomczyk | Nurse Consultant | Report submitted by and involved in notification of plan of correction approval |
| Michael Bernardi | Assistant Administrator | Contacted personnel during complaint investigation |
| Karen Chadderton | Administrator | Named in multiple letters and plan of correction correspondence |
| Heidi Caron | Supervising Nurse Consultant | Signed important notice letters regarding plan of correction |
| Peggy Ortola | Nurse Consultant | Submitted desk audit report |
| Norma Schuberth | Supervising Nurse Consultant | Signed letter regarding plan of correction |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Registered Nurse #6 | MDS Director | Supervises MDS assessments and responsible for ensuring MDS accuracy |
| Licensed Practical Nurse #6 | LPN | Acknowledged miscoding of hospice services and prognosis in MDS assessment |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| LPN #5 | Licensed Practical Nurse | Named in deficiency related to failure to replace pressure ulcer dressing timely and inaccurate documentation |
| RN #5 | Registered Nurse | Named in deficiency related to wound care and RN assessment |
| LPN #4 | Licensed Practical Nurse, Nursing Supervisor | Named in deficiency related to failure to timely assess Resident #621 after change in condition |
| RN #8 | Registered Nurse | Involved in supervision and documentation related to Resident #158 smoking and elopement incidents |
Inspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Norma Schuberth | Supervising Nurse Consultant | Signed letter directing submission of plan of correction |
| Karen Chadderton | Administrator | Named as facility administrator receiving the notice |
| Director of Nursing | Responsible for monitoring plan of correction for violations #1 and #2 | |
| Director of Social Services | Responsible for monitoring plan of correction for violation #3 | |
| Director of Food Management | Interviewed regarding dishwasher sanitizing violation |
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Karen Chadderton | Administrator | Personnel contacted during the inspection |
| Lucia Dike | DNS | Personnel contacted during the inspection |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lucie Dike | Personnel contacted during the inspection |
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